Provider Demographics
NPI:1972886323
Name:TAVERAS, MICHELLE CHRISTY (MSW, PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CHRISTY
Last Name:TAVERAS
Suffix:
Gender:F
Credentials:MSW, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:904-376-3998
Practice Address - Street 1:4844 DEER LAKE DR W STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-4406
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-390-7431
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8925103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16189128Medicare PIN